RFI 1957 previously indicated there is no way in 005010X279 to indicate a telemedicine benefit on a 270 or 271.
As most telemedicine benefits are typically the same benefits or services that are done in an in person setting, it's my opinion that, because the III when being used to represent place of service, place of service being an external code list (Code Source 237) that is maintained by CMS, the value "02" can be used to indicate the place of service "telehealth" as it's defined as: "The location where health services and health related services are provided or received, through a telecommunication system. (Effective January 1, 2017)" (https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set)
The telehealth description on the CMS website for code value 02 satisfies the need to indicate what service or benefit is available via telecommunication (which may be interpreted as the same as telemedicine), and is allowed to be used in the current 5010X279 270/271, as it's a named external code source, where the III*ZZ*02 with an EB03 service type code may be sent rather than "MSG*Telemedicine benefit" and further supports the codification of the information.
To support the idea of codifying information vs. sending that information in an MSG segment, the use of the III code value ‘02’ from the place of service external code set (code source 237) is appropriate.
For education: 005010X279 was published in 2008 where the III03 listed code values did not include ‘02’ in the element note. RFI 1957 was published in 2015 providing the solution to use MSG to note the telemedicine benefit applicability. The CMS place of service code value ‘02’ was effective January 1, 2017.
The III segment situational rule indicates that the III must be used in only two situations. One where there is a 270 III segment present and the information was used to determine the eligibility and benefit response, and two, the III is used to indicate limitations in the benefits that are returned in anywhere in the 2110 loop by way of any segment, element or code value used, consistent with those segment and element situational rules. It is not exclusively dependent on the use of EB01 = F (limitations) and may be used with any appropriate code value returned in EB01.
The intent of the workgroup is that the second part of the situational rule should be understood that there could be benefit applicability differences based on the III segment, such as the III03, and the entire 2110 loop needs to be taken into context to determine what the extent of the limitation is and what the III is differentiating.
For example, if the III is returned with telemedicine (III03 = 02), and a copay (EB01 = B) is returned with a monetary amount (EB07) of as $10.00 for a consultation (EB03 = 3) and another occurrence of the EB segment is returned with a copay (EB01 = B) for a consultation (EB03 = 3) and a monetary amount (EB07) of $25.00 with a III03 (place of service) of 11 (office), this indicates that the copay that is to be collected, and limited to, no more than $10.00 for a benefit of consultation with a place of service telemedicine vs. a $25.00 copay for the same benefit in an in-person office setting.
Another example would be returning EB01 = C (deductible) with an EB03 = 2 (surgery), EB07 of $1500.00 and EB06 =23 (calendar year time-period qualifier) with a III03 of 21 (inpatient hospital) and EB12 = Y (in network) vs. returning EB01 = C (deductible) with an EB03 = 2 (surgery), EB07 of $3500.00 and EB06 =23 (calendar year time-period qualifier) and EB12 = N (out of network) with a III03 of 21 (inpatient hospital). In summary, this example shows that the benefits are limited in nature by the type of place of service and network as the deductible amount will be different depending.
The above example supports the second part of the situational rule whereby it is stated that the III is used to “…identify limitations of the benefits explained in the corresponding Loop 2110C…”. The first example shows the place of service affects the copay amount, and the second example shows that the place of service and in network/out of network status affects the deductible amount.
As a result of the addition of place of service code value ‘02’, the III03 must be used when consistent with the III segment situational rule (with the explanation of the intent of the III segment’s usage above). This RFI response is in line with the requirements set forth in 1.4.12and the 2110C/D MSG segment note that states: Under no circumstances can an information source use the MSG segment to relay information that can be sent using codified information in existing data elements (including combinations of multiple data elements and segments).If the information cannot be codified, then cautionary use of the MSG segment is allowed as a short-term solution. It is highly recommended that the entity needing to use the MSG segment approach X12N with data maintenance to solve the long-term business need, so the use of the MSG segment can be avoided for that issue.